Classified Employee Application

Personal Information
Name
Date

MonthDayYear
Date
Mailing Address
City
State
ZIP
Home Phone
Work Phone
How did you become aware of this position?
Position for which you are applying?
Do you have commitments to another employer which might affect your employment with us?
Educational Data

Schools (List Name, City & State)

	Dates Attended	Course or Major	Diploma or Degree?
High School
College
College

List any additional skills, experience or other relevant qualifications (including any military experience)
Employment History
List present employer or most recent employer first. Indicate which employers you do not wish us to contact.
Employer
Do Not Contact
Address
Phone
Supervisor
Employed from
to
Reason for leaving
Employer
Do Not Contact
Address
Phone
Supervisor
Employed from
to
Reason for leaving
Employer
Do Not Contact
Address
Phone
Supervisor
Employed from
to
Reason for leaving
General Information
Are you authorized to work in the United States?

YesNo
Are you over the age of 18?

YesNo
Are you willing to undergo a pre-employment physical exam?

YesNo
Have you previously applied for employment at this school district?

YesNo
If yes, when?
Have you previously been employed by this district?

YesNo
If yes, when and what position?
Are any of your relatives employed by this school district?

YesNo
If yes, please list name and position
How many total years of employment experience do you have in a job similiar to the one for which you are applying?
Please include any other information you think would be helpful to us in considering you for employment, such as additional work experience, activities, accomplishments, etc. You may exclude all information indicative of age, sex, race, religion, color, national origin and handicap
CRIMINAL RECORD
The term "convicted" includes a guilty plea, a plea of nolo contendere or no contest, a deferred judgement or an adjudication of guilt or delinquency as a minor.

If you answer "yes" to any of the following questions, you must provide detail.
Have you ever been convicted of a felony
Have you ever been convicted of a serious misdemeanor
Details, if needed.
CRIMINAL RECORDS CHECK CONSENT
I agree to sign a Waiver authorizing the District to obtain a check of my criminal history, and I further agree to provide all information necessary to obtain this criminal history check. Please provide your date of birth or social security number on the line below so we may obtain your criminal history.
Date of Birth or Social Security Number
I hereby certify that the information given in this application is correct and true and I authorize the District to obtain a check of my criminal history.
Signature

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Date

MonthDayYear
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The MOC-Floyd Valley Community School District will not discriminate on the basis of race, color, national origin, gender, disability, religion, creed, marital status, sexual orientation or gender identity.
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Personal Information

Educational Data

Employment History

General Information

CRIMINAL RECORD

CRIMINAL RECORDS CHECK CONSENT